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2. Thank you for your inquiry into Community Health Education. Please complete the form below and a staff member will contact you.
4. First Name*
5. Last Name*
7. Email Address*
8. Phone Number*
10. Please indicate your preferred method of contact*

    1. Email
    2. Phone
12. Please indicate which opportunity you are interested in.
14. Group Education at Your Location

    These learning opportunities are offered in a group setting on site at your location. PLEASE ALLOW AT LEAST 3 WEEKS FOR SCHEDULING

    1. Lead, the Hidden Danger
    2. Radon in the Home
    3. What's in the Water
    4. Cooking Demonstrations
    5. Question, Persuade, Refer: QPR (request on site training)
    6. Grapevine
    7. Vaping Education for Youth
    8. Hidden in Plain Sight
15. Group Education at Health & Human Services

    These learning opportunities are offered in a group education environment on site at Health and Human Services. 

    1. Baby Basics (Breastfeeding/Infant feeding)
    2. Question, Persuade, Refer QPR (notify me of the next community session)
17. How did you hear about this education opportunity?*

    1. Facebook
    2. Press release

    1. Flyer
    2. Walworth County website

    1. School staff
    2. Healthcare provider

    1. Friend
    2. Other (please explain below):
19. If other, explain:

21. Please expect a staff member to follow up with a phone call or email. If you have questions please contact walcoph@co.walworth.wi.us or 262-741-3200.

Leave This Blank:


23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit

* indicates a required field